C. M Haddad

Resultados tardios da operação de Heller associada à fundoplicatura no tratamento do megaesôfago: análise de 83 casos

BACKGROUND: Retrospective study of the late results of the Hellers cardiomyotomy and fundoplication for the treatment of the megaesophagus. MATERIAL AND METHODS: Were studied 83 patients with a follow-up from one to 186 months (average 40.0±47.4 months). The fundoplications used were in three plans in 15.7% and posterior in 83.1%. The main pre-operatory complain was disphagia followed by regurgitation and loss of weight. Chagas, Disease as the etiology was confirmed in 72.3% of the patients. RESULTS: In the follow-up 55.4 % of the patients were assymptomatic, 34.9% complained of sporadic dysphagia, 14.4% of heartburn, 8.4% of regurgitation and 2.4% did not changed the dysphagia, these being re-operated and had improvement the symptoms. Gastro-esophageal reflux was noted in 8.4% of the patients. Other late complications were par-esophageal hernia, sliping of the fundoplication, Barrett esophagus and cancer. CONCLUSIONS: The necessity of a long-term clinical and endoscopical follow-up, even after surgery, owing to the possibility of late complications, especially cancer was emphasized. The late results are good in relation to the dysphagia. Myotomy is proposed as an alternative to patients with advanced megaesophagus with bad clinical conditions who can not be submitted to an esophagectomy.

Obstrução do íleo terminal por mucosa gástrica heterotópica

Heterotopic gastric mucosa situated in the small bowel distal to the Treitz suspensory ligament is very rare, except in Meckels diverticulum and in intestinal duplications. There are two forms of this disease, congenital and acquired. The former is secondary to inflammatory bowel disease. The main difference between these forms is histological, although determining diverse physiopathological aspects. A case of a 34 year old man with heterotopic gastric mucosa in the terminal ileum manifested by intestinal obstruction is reported. He was treated surgically by enterectomy of two small bowel segments, both reconstructed by primary suture. His postoperative course was remarkable. The histopathologic study showed a typical pattern of the acquired type because of the presence of antral the antral mucosa and intense fibrosis. That is probably related to intestinal tuberculosis, but was not histologically confirmed. Individual and family recent history of pulmonary tuberculosis corroborates the suspicion. This is a unique report in the literature, among 28 other heterotopic gastric mucosa situated in the jejunum and ileum.A mucosa gastrica ectopica localizada no intestino delgado, distal ao ligamento de Treitz e muito rara, excetuando-se a encontrada habitualmente no diverticulo de Meckel e na duplicacao intestinal. Existem formas congenita e adquirida, sendo esta ultima secundaria a processos inflamatorios intestinais. As diferencas entre estas formas sao basicamente histologicas, determinando no entanto aspectos fisiopatologicos distintos. Apresentamos caso de mucosa gastrica ectopica em paciente de 34 anos de idade, manifestada por obstrucao do ileo terminal. Submetido a duas enterectomias e anastomoses primarias, apresentou boa evolucao pos-operatoria. O aspecto histopatologico, tipico da forma adquirida com mucosa antral e intensa fibrose, foi provavelmente relacionado a quadro recente de tuberculose intestinal, porem nao confirmada histologicamente. O antecedente de tuberculose pulmonar recente na familia, aliado a linfoadenomegalia mesenterica encontrada a operacao, sustentam tal suspeita. Este e fato inedito na literatura dentre as outras 28 publicacoes de heterotopia gastrica no jejuno e ileo.

Hemorragia digestiva por fístula de artéria subclávia direita anômala com o esôfago

Bleeding from an arterio-esophageal fistula is a rare and nearly lethal condition and surgical treatment is the only curative option. We report a case of bleeding from a fistula from an aberrant right subclavian artery to the esophagus. Diagnosis was made only at necropsy, despite of three previous laparotomies. This anatomical variation is found in 0.5% of the general population. Development of a communication between this artery and the esophagus, secondary to aneurysmatic dilatation or to prolonged nasogastric intubation, as probably occurred with this patient, is a extremely rare condition. Surgical treatment depends on the early recognition of clinical signs of the arterio-esophageal communication, before the onset of systemic complications of hypovolemic shock.Bleeding from an arterio-esophageal fistula is a rare and nearly lethal condition and surgical treatment is the only curative option. We report a case of bleeding from a fistula from an aberrant right subclavian artery to the esophagus. Diagnosis was made only at necropsy, despite of three previous laparotomies. This anatomical variation is found in 0.5% of the general population. Development of a communication between this artery and the esophagus, secondary to aneurysmatic dilatation or to prolonged nasogastric intubation, as probably occurred with this patient, is a extremely rare condition. Surgical treatment depends on the early recognition of clinical signs of the arterio-esophageal comunication, before the onset of systemic complications of hypovolemic shock.